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Provider Questionnaire
Key Medical utilizes the below information to determine which revenue-generating ancillaries are applicable to your practice. Once submitted, a member of our team will contact you within 5 business days.
Facility Name
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
Primary Contact First Name
*
Primary Contact Last Name
*
Primary Contact Email
*
Direct Message Address
(May Add Later)
Provider First Name
*
Provider Last Name
*
Provider Title
*
NPI
*
Number of Providers
*
(including Mid-Level)
Number of Locations
*
Facility Website
Number of Active Patients
*
Commercial Percentage
*
Medicare Percentage
*
Medicaid Percentage
*
Managed Medicare Percentage
*
What Lab Services are being done In-House?
*
Are you currently providing injections to your patients in your clinics?
*
Yes
No
How many patients do you treat per month?
*
Who Handles Your Billing?
*
In-house
Outsourced to a 3rd Party
Where do you send your patients?
Approximately how many do you refer out per month?
What brand name products do you purchase?
What are the top 3 surgical procedures you perform?
(Joint Replacement, Wound Related, Fusion, etc.)
What surgical wound care products do you utilize?
(Collagens, Dressings, etc)
Are you currently testing for Fungal Infections or Wound Swab Analysis?
Yes
No
What Lab Services are being done In-House?
Are You Interested in Our Capital Services?
Yes
No